Healthcare Provider Details

I. General information

NPI: 1750101606
Provider Name (Legal Business Name): MICHAEL R. WIESNER DDS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/15/2024
Last Update Date: 10/15/2024
Certification Date: 10/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

385 BERT KOUNS LOOP STE 700
SHREVEPORT LA
71106-8163
US

IV. Provider business mailing address

2557 VIKING DR
BOSSIER CITY LA
71111-2103
US

V. Phone/Fax

Practice location:
  • Phone: 318-688-9330
  • Fax: 318-212-6539
Mailing address:
  • Phone: 318-606-7622
  • Fax: 318-212-6539

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: INGER WHITTINGTON
Title or Position: INSURANCE BILLING LEAD
Credential:
Phone: 318-606-7622